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Submitting & Billing Claims

CenCal Health’s Claims department is committed to processing your claims as quickly and accurately as possible.

In general, CenCal Health follows the benefit and payment guidelines as published by the State of California’s Medi-Cal program. This information can be found on the Medi-Cal website www.medi-cal.ca.gov

W-9 Taxpayer Information Form

Please submit a new W9 if you are changing your “Mail-To” and “Pay-To” addresses, and legal business name or ownership.

Timelines for All Lines of Business

Original (or initial) Medi-Cal claims must be received by CenCal Health within six months following the month in which services were rendered or the following payment reductions may apply:

Claims received during the 7th, 8th or 9th month after the month of service will have final payment reduced by 25%.
Claims received during the 10th, 11th or 12th month after the month of service will have final payment reduced by 50%.
Claims received after the 12th month following the month of service will be denied.

There are exceptions to these billing limits. These can be found in the State of California’s Medi-Cal Billing Manual and at the following links:

For HF, HK, AIM and IHSS: claims must be submitted within 180 days from the date the service was rendered or claim will be denied, unless Provider can prove extenuating circumstances.

Other General Billing Information

Medi-Cal (SBHI & SLOHI)

Billing and benefit information for all Providers can be accessed on the State of California’s Medi-Cal Home Page. You may access this information at the link below:

Medi-Cal: Provider Manuals

CPT & HCPCS Codes:

CenCal Health, through instructions received from the Department of Health Care Services, implements CPT and HCPCS code updates each year. However, because of the time required for the State to determine rate and benefit status for each new code, Medi-Cal does not recognize new, deleted or changed codes on January 1 of each year.

Once these determinations have been made, usually in late summer, notification will be sent to Providers which will announce the date of service in which the new codes may be utilized. Because of this delay, it is important not to submit new codes to the Medi-Cal program until notified of such. In the same light, Providers should also continue to use deleted codes until notified to discontinue.

Healthy Kids/Health Families/AIM

Prior Authorization for Services

The Authorization and Referral process outlined in the Provider Section under “Authorization” in CenCal Health’s website applies to all Lines of Business.

Procedure Code Tips

Providers must use the HIPAA Compliant CPT, HCPCS codes and modifiers for the date(s) of service on the claim.

To verify that the service being provided is for an appropriate diagnosis, please contact your Claims Service Representative for assistance.

In an effort to assist with billing, the following is a list of procedure codes that require a valid diagnosis code which must be related to the service rendered. Unrelated or invalid diagnosis codes are subject to denial. Click here for the list of procedure codes.

For a list of procedure codes listed as Non-Benefits for Physician services, click here. For a list of procedure codes listed as Non-Benefits for Laboratory services, click here .

Certain procedure codes are used as informational, or reporting purposes only and do not receive reimbursement. CenCal Health does their best to keep this list updated as changes occur. In addition, the most commonly used procedures and the EOP messages you may be receiving on your claims are located here. This list will provide you with additional clarification on the editing that occurs on CenCal Health’s claims.

Common Denials

For a list of the most common Healthy Kids and AIM denials, as well as tips on how to make corrections to those denials, please click on the link Most Common Denials. For questions about denials not listed on this attachment, please contact your Claims Service Representative, at 805-562-1083 for further assistance.

ICD-9 & ICD-10 Diagnosis & Procedure Codes

CenCal Health follows the yearly October 1 update to ICD for all of our programs.
CenCal Health will adopt the ICD-10 diagnosis and procedure codes on October 1, 2015.

Access the following:

Claim Adjudication Edits

CenCal Health employs industry standard edits for all lines of business when adjudicating a claim. Most are standard edits such as verifying the member’s eligibility, whether or not the services billed are plan benefits, the validity of the codes submitted, and if authorization requirements have been met. In addition, there are claim edits set forth by the Department of Health Services related to Medi-Cal benefit limitations that may affect editing.

For All lines of business CenCal Health also utilizes the procedure-to-procedure (PTP) NCCI edits that are published by CMS. The NCCI edit tables can be accessed at this link below, which will take you to the Main Page that contains the 2 sets of Hospital NCCI Edits and the 2 set of Physician NCCI edits.

PTP Coding Edits – Centers for Medicare & Medicaid Services

Surgical Codes

To access the list of surgical codes with the number of follow-up days for each, click here: Surgical Follow Up Days – 2015

Child Health & Disability Prevention (CHDP)

Effective July 1, 2016, CenCal Health will begin administering the Child Health & Disability Prevention (CHDP) program covering members within Santa Barbara and San Luis Obispo counties. Providers must be certified under Medi-Cal, CHDP and Vaccines For Children (VFC) in order to provide these services. Below is the CHDP code crosswalk for purchased vaccines and the CHDP Code Conversion.

CHDP Code Crosswalk for Purchased Vaccines

CHDP Code Conversion

Billing Tips

Avoiding claim denials and reductions in payment

Claims submitted with dates of service prior to July 1, 2016, will be denied;
Verify eligibility before rendering services and submitting your claim. Members who are not Medi-Cal eligible will be denied;
Referral Authorization Forms (RAF’s) are required when the provider is not the members current PCP;
Medi-Cal billing timelines apply. Claims received with dates of service beyond 6 months without a valid delay reason code will be reduced in payment;
Do not resubmit a new claim when making a correction to a previously submitted or denied claim as this can result in a duplicate claim denial.

Please contact your Claims Service Representative for all corrections, inquires and/or questions on your CHDP claims.

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